Answers

1. What are the types of health care services whose reimbursement may be submitted to c. 32 Out-of-Network Arbitration ("c. 32 OON Arbitration")?

Reimbursement for inadvertent or emergency/urgent health care services rendered in New Jersey by an out-of-network health care provider that is New Jersey licensed or certified may be submitted to c. 32 OON Arbitration. Services rendered by network health care providers and services rendered by out-of-network health care providers on a voluntary basis are not subject to c. 32 OON Arbitration.

Inadvertent out-of-network health care services are health care services that are covered under a managed care health benefits plan that provides a network and are provided by an out-of-network health care provider when a covered person utilizes an in-network health care facility for covered health care services and, for any reason, in-network health care services are unavailable in that facility. Inadvertent out-of-network health care services include laboratory testing ordered by an in-network health care provider and performed by an out-of-network bio-analytical laboratory.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists where there is inadequate time to make a safe transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of the woman or the unborn child.

Emergency and urgent health care services include, but are not limited to: (1) medical and psychiatric care which must be available 24 hours per day, 7 days per week; (2) coverage for trauma services at any designated Level I or II trauma center as medically necessary; (3) out-of-service area medical care when medically necessary for urgent or emergency conditions where the member cannot reasonably access in-network health care services; (4) prehospital care and hospital services regardless of location where medically necessary for injury or emergency illness; and (5) upon arrival in a hospital, coverage of a medical screening examination, as required by the Federal Emergency Medical Treatment and Active Labor Act.

With respect to c. 32 OON Arbitration, a carrier as an entity that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including an insurance company authorized to issue health benefits plans, a health maintenance organization, a health service corporation, a hospital service corporation, a medical service corporation, a multiple employer welfare arrangement, the State Health Benefits Program, the School Employees’ Health Benefits Program or any other entity providing a health benefits plan.

8. How does a carrier process a claim for out-of-network inadvertent or emergency/urgent health care services?

Upon receipt of a claim for inadvertent or emergency/urgent health care services rendered in New Jersey by an out-of-network health care provider licensed or certified in New Jersey, a carrier must either pay the charges as billed or, within 20 days of receipt of the claim, advise the out-of-network health care provider that his or her billed charge exceeds the amount that the carrier initially determined is the allowed charge/allowed amount for those services and process the claim based on the initial allowed charge/allowed amount.

9. How does a provider of out-of-network inadvertent or emergency/urgent health care services dispute the carrier’s initial allowed charge/allowed amount?

The out-of-network provider must contact the carrier to reject the initial allowed charge/allowed amount within 30 days of receipt of the carrier’s notification that the carrier has determined that the provider’s billed charge exceeds the amount the carrier has initially determined is the allowed amount/allowed charge for such services. A provider’s failure to make such contact with the carrier will bar c. 32 OON Arbitration of the claim for inadvertent or emergency/urgent services.

10. What occurs after the out-of-network health care provider of inadvertent or emergency/urgent health care services notifies the carrier that it disputes the carrier’s initial allowed charge/allowed amount?

The carrier and the out-of-network provider have 30 days from the out-of-network provider’s receipt of the carrier’s notice that it has determined that the provider’s billed charge exceeds the carrier’s initial allowed charge/allowed amount to negotiate a settlement. If settlement is not reached within the 30-day negotiation period, within seven days after expiration of the 30-day negotiation period, the carrier must notify the out-of-network provider of the carrier’s final offer allowed charge/allowed amount and remit additional payment of its portion of the final offer allowed charge/allowed amount to the provider.

C. 32 OON Arbitration is available if: (1) the claim is for inadvertent and emergency/urgent health care services rendered in New Jersey by an out-of-network health care provider who is licensed or certified in New Jersey where the date of service is on or after August 30, 2018, (2) the person who received the service was covered under a health benefits plan issued in New Jersey by a carrier or by a self-funded health benefits plan that covers New Jersey residents and opted in to c. 32 OON Arbitration, (3) the out-of-network health care provider must request c. 32 OON Arbitration within 30 days of receipt of the carrier’s notification of its final offer allowed charge/allowed amount, (4) the difference between the provider’s final offer allowed charge/allowed amount and the carrier’s final offer allowed charge/allowed amount must be $1,000 or higher, (5) all applicable preauthorization and notice requirements of the health benefits plan must be satisfied, and (6) the matter must not involve a dispute as to whether a treatment or service is medically necessary, experimental or investigational, cosmetic or whether an in-plan exception should be granted. See questions 18 – 20 for a discussion of c. 32 OON Arbitration involving self-funded health benefits plans that do not opt-in to c. 32 OON Arbitration.

12. What should be included in a request for c. 32 OON Arbitration and to whom should such requests be submitted?

Requests for c. 32 OON Arbitration should be submitted to MAXIMUS, Inc. ("MAXIMUS") through its portal. The request should include the "Application for Arbitration of Payment for Inadvertent, Emergency or Urgent Out-of-Network Health Care Services" ("c. 32 OON Arbitration Application") form. You may click here to download the form.

The request should include the final offer allowed charge/allowed amounts of both the provider and the carrier, a "Consent to Representation and Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims" form if the covered person’s medical information accompanies the arbitration request and the applicable fee.

MAXIMUS will acknowledge receipt of a c. 32 OON Arbitration Application to the parties and provide notice of any deficiencies within seven business days of receipt of a c. 32 OON Arbitration Application. If the initiating party fails to correct the deficiencies within 15 days, the c. 32 OON Arbitration Application will be deemed withdrawn.

14. What fees are payable if a c. 32 OON Arbitration Application is rejected?

If a c. 32 OON Arbitration Application is rejected based upon information submitted with the application, the initiating party’s review fee will be retained, and its arbitration fee refunded. If a c. 32 OON Arbitration Application is initially accepted, but later rejected as ineligible based upon information submitted in whole or in part by the non-initiating party, the review fees of both parties will be retained, and the arbitration fees of both parties will be refunded.

The only evidence admissible in the c. 32 OON Arbitration proceeding and on which the arbitrator’s determination may be made, are the documents submitted to, requested by and accepted by MAXIMUS from the parties to the dispute. In-person or telephonic testimony will not be permitted.

Within 30 days of the receipt of a complete c. 32 OON Arbitration Application and accompanying documents, the arbitrator will issue a decision subject to the following requirements:

The decision must be in writing;

The decision must select either the final offer allowed charge/allowed amount of the out-of-network health care provider or the final offer allowed charge/allowed amount of the carrier as the amount awarded;

The decision will split the costs of the arbitration between the parties to the arbitration, unless the carrier is found to not have acted in good faith;

The decision will not award legal fees or costs; and

The decision will be binding on all parties and will only be subject to vacation or modification in accordance with N.J.S.A. 2A:24-1.

If the out-of-network health care provider prevails in the arbitration, the carrier must remit payment of the difference between its portion of its final offer allowed charge/allowed amount and the arbitration award within 20 days of the date of the arbitration decision. If the carrier fails to remit payment within this timeframe, interest of 12 percent per annum will accrue, starting on the 21st day after the date of the arbitration decision. Interest will terminate on the date of payment, but no later than 150 days after the date of the claim receipt, unless the parties agree to a longer period of time.

18. Does a c. 32 OON Arbitration award increase the amount a covered person pays as his or her cost sharing liability?

No. The carrier must pay the arbitration award without any increase in the covered person’s cost-sharing liability. The covered person’s cost sharing liability is calculated based on the carrier’s final allowed charge/allowed amount offer.

19. How does a c. 32 OON Arbitration procced where the person is covered by a self-funded health benefits plan that does not opt-in to c. 32 OON Arbitration?

For any self-funded health benefits plan which covers New Jersey residents and that does not opt to participate in c. 32 OON Arbitration, the member of the self-funded plan or the out-of-network health care provider may request binding arbitration for claims for inadvertent and/or emergency/urgent out-of-network health care services, if there is no resolution of a payment dispute within 30 days after the member is sent a bill for these services. Specifically, an out-of-network health care provider may bill the member once upon the initial adjudication of the claim for inadvertent and/or emergency/urgent out-of-network health care services by the self-funded plan. Thereafter, a 30-day negotiation period is commenced, during which time, the out-of-network health care provider must not collect or attempt to collect reimbursement from the member, including through the initiation of collection proceedings. After the expiration of the 30-day negotiation period, either the out-of-network health care provider or the member may initiate arbitration. The out-of-network health care provider may not balance bill the member or initiate collection activity until the out-of-network health care provider has filed a request for arbitration. These arbitrations are currently administered by MAXIMUS. Voluntary out-of-network claims are not eligible for arbitration.

The member was enrolled in the self-funded plan at the time the inadvertent and/or emergency/urgent services were rendered;

The member has been balance billed by an out-of-network health care provider for the inadvertent and/or emergency/urgent services rendered;

The c. 32 OON Arbitration Application includes, or the member has previously submitted, a fully-executed “Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims” form in the event that the member’s confidential information accompanies the arbitration request; and

The party initiating the arbitration request has submitted all information requested by MAXIMUS, as necessary, with the c. 32 OON Arbitration Application and the applicable fee.

MAXIMUS will not accept the request unless 30 days have elapsed from issuance of the out-of-network health care provider’s bill to the member

21. How will a c. 32 OON Arbitration award involving a self-funded health benefits plan that does not opt-in to c. 32 OON Arbitration differ from a c. 32 OON Arbitration award involving a health benefits plan issued by a carrier or by a self-funded plan that opts-in to c. 32 OON Arbitration?

Arbitration decisions involving self-funded plans that do not opt-in to c. 32 OON Arbitration will award an amount that the arbitrator determines is reasonable for the inadvertent and/or emergency/urgent out-of-network service rather than the final offer allowed charge/allowed amount of the carrier or provider. Such decisions will split the costs of the arbitration between the parties to the arbitration, unless the payment would pose a financial hardship to the member, which can be demonstrated by total family income below 250% of the Federal Poverty Level. Finally, decisions involving self-funded plans that do not opt-in to c. 32 OON Arbitration will only be binding on the member and the out-of-network health care provider and will include a non-binding recommendation to the entity providing or administering the self-funded health benefits plan of an amount that would be reasonable for the inadvertent and/or emergency/urgent out-of-network service.